Evaluating and managing severe headache in the emergency department

ABSTRACT

Introduction: Headache is the fifth most common reason to visit an emergency department (ED). In most of the cases, headache is benign and has a primary origin, with migraine as the most common diagnosis. Inappropriate use of ED for non-emergency conditions causes overcrowding, unnecessary testing, and increased medical costs.

Areas covered: All stages of headache management in ED, from the reasons to go there, the diagnosis that is made and the investigations necessary to make it, to get to the therapies administered and those prescribed at discharge, if there were any. Finally, the authors evaluated the habit of recommending medical follow-up and how often the headache is still present at discharge or returns within 24 hours.

Expert Opinion: Primary headaches are underdiagnosed, misdiagnosed, and the majority do not receive drug therapy either in ED or on discharge, and in cases where the therapy is prescribed is not specific. Increase the number of primary care medical services, spread the ‘headaches culture’ among GPs and ED doctors, the adoption of ICHD in the diagnostic protocols used in EDs and a fast referral to a headache center could decrease the inappropriate use of ED and improve the headache management in the emergency units.

KEYWORDS:

• Acute treatment
• cluster headache
• migraine treatment
• primary headache
• secondary headache

Article highlights

• Headache is the most common complaint among ED patients with neurological disorders and in most of the cases it is benign and has a primary origin and migraine is the most common diagnosis.

• Primary headaches can be successfully managed at primary care level while drugs resistant patients should be referred to specialist centers. However, these disorders are still underdiagnosed and undertreated, which is the main cause for an inappropriate use of EDs.

• Inappropriate use of ED for non-emergency conditions causes overcrowding of emergency units, unnecessary testing, increased medical costs, and burdens on medical service providers.

• In the EDs, primary headaches are underdiagnosed and misdiagnosed and the majority of patients do not receive drug therapy either in ED or on discharge, and in cases where the therapy is prescribed is not specific.

• Headache is still present at discharge in more than half of the patients and half of them report their headache returns within 24 hours of leaving the ED.

• Increase the number of medical services at a primary care level, spread the ‘headaches culture’ among GPs and ED doctors, the adoption of ICHD in the diagnostic protocols used in EDs and a fast referral to a headache center could decrease the inappropriate use of ED and improve the headache management in the emergency units.

Declaration of interest

1. Negro has received personal fees for advisory boards and speaker honoraria from Allergan, Eli Lilly, Novartis and Teva. P. Martelletti has received personal fees for advisory boards as well as research and educational grants to the University Department from Allergan, Eli Lilly, Novartis, and Teva. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.